Left Internal Carotid Artery Terminus Research Articles

PS-R06-5: CASE REPORT OF INCREASED ARTERIAL STIFFNESS IN MOYAMOYA DISEASE IN A YOUNG CHINESE PATIENT PRESENTING AS RECURRENT STROKE IN SINGAPORE

Introduction: Moyamoya disease (MMD) is characterised by progressive stenosis of distal ICA and the resulting hazy network of basal collateral vessels. Increase arterial stiffness in MMD is not well described. Case report: We describe a young patient ML, a 42-year-old Chinese female, presented to hospital in June 2015 with headaches, on a background of known hypertension diagnosed at the age of 28 years. Her systemic examination was normal. Investigations were unremarkable. She was followed in General Medicine (GM) clinic from 2015, which ruled out secondary causes of hypertension, including renovascular disease, renal artery stenosis, phaeochromocytoma and hyperthyroidism. ML was treated for presumptive essential hypertension. Over time, her BP remained stable on candesartan 16 mg and bisoprolol 2.5 mg once daily. She continued to have intermittent headaches. Recurrent ischaemic strokes and diagnosis of Moyamoya disease ML presented with intermittent right-sided facial numbness in February 2017. A magnetic resonance imaging (MRI) brain done showed no acute infarct or hemorrhage, but moderately severe narrowing of the left terminal internal carotid artery (ICA), associated with poor flow signals in both the A1 segment of the left anterior cerebral artery (ACA) and the M1 segment of the left middle cerebral artery (MCA). She was started on clopidogrel 75 mg and atorvastatin 40 mg daily. The second stroke occurred in March 2019, when ML presented with acute right upper and lower limb weakness, and right facial, upper and lower limb numbness. Magnetic resonance angiography (MRA) demonstrated severe stenosis at the left terminal ICA, also involving the left M1 and A1 segments; collateral flow was observed. The third stroke happened in April 2019, presenting with acute right-sided facial and upper limb weakness, with BP of 201/86mmHg. MRI and MRA of the brain revealed new acute infarcts scattered in the territories of the left MCA and ACA. A CT angiogram re-demonstrated severe steno-occlusive disease involving the left ICA T-junction and left M1 and A1 segments, with extensive basal collaterals. In light of these findings, Moyamoya disease (MMD) was diagnosed. ML underwent a left external carotid-internal carotid bypass in June 2019. An arterial stiffness study by syphgmoCor in June 2020 using markedly increased arterial stiffness. Conclusion: We present first and very rare case of hypertension in a young patient with MMD associated with increased arterial stiffness. Systemic vascular affection in MMD may be the cause of increased arterial stiffness.

INCREASE ARTERIAL STIFFNESS IN MOYAMOYA DISEASE PRESENTING WITH HYPERTENSION AND STROKE: A NOVEL FINDING IN A VERY RARE CASE IN SINGAPORE

Arterial stiffness in Moyamoya disease (MMD) has not been described before in literature. We describe a young 42 year-old lady who initially presented as hypertensive urgency and recurrent stroke and was later diagnosed with MMD. We would like to highlight increased arterial stiffness as a cause of hypertension in patients with MMD.This is a case report of a 42 year old lady 42 year Singaporean lady presented in 2015 with headache and transient ischemic attack(TIA) and systolic blood pressure was 200mmHg. She was diagnosed with hypertension at the age 28 years and started on telmisartan 40 mg OD.There was no end organ damage and secondary hypertension work up was negative. She has recurrent TIAs and was started on T. atorvastatin 40 mg ON and T clopidogrel 75 mg OD in Feb 2017.She presented with stroke in March 2019, and MRI revealed left posterior temporal-parietal infarct, MRA revealed severe stenosis of left terminal internal carotid artery(ICA).She presented with recurrent stroke in April 2019 and MRI/MRA revealed scattered acute infarcts in left MCA and ACA territories and severe steno-occlusive disease involving left ICA. She underwent left external carotid -internal carotid bypass in June 2019. In light of these findings, MMD was diagnosed.She was started on T spironolactone and her blood pressure was kept in stable range of 130-150/80-95mmHg. An arterial stiffness study by SphygmoCor in June 2020 showed markedly increased arterial stiffness with markedly increased augmentation index, aortic augmentation pressure, aortic systolic pressure and aortic pulse pressure for the patient's age.We present an interesting and rare case of hypertension in a young patient with MMD associated with increased arterial stiffness, with no renovascular disease. This is one of the first cases reported in MMD with increased arterial stiffness. We also highlighted genetic studies and case reports that have suggested that the histopathological process underlying Moyamoya vessels may also affect systemic vessels. We hope that this article will inspire more research on the relationship between MMD and hypertension, particularly in terms of how systemic vasculature is affected.

More Than Meets the Eye

A 56-year-old male with a known history of sickle cell disease (SCD) with HbSC and progressive deafness presented to the hospital with increased left-sided weakness accompanied by worsening confusion for the past 5 days. He experienced a multiorgan crisis requiring plasmapheresis 10 years prior. He had lived independently until moving in with his brother because of progressive cognitive problems. On presentation, he appeared mildly confused, with mild bilateral proximal weakness, and scored a 3 on the National Institutes of Health Stroke Scale. Hemoglobin was 12.9, and peripheral blood smear showed occasional sickle cells. Serum electrophoresis demonstrated 52% hemoglobin S (HbS) and 44.7% hemoglobin C (HbC). Magnetic resonance imaging (MRI) brain revealed multifocal punctate areas of restricted diffusion of acute infarction affecting the deep white matter and the cortex. These were superimposed on diffuse volume loss and multifocal areas of old lacunar infarction (Figure 1). Computer topographic angiography showed severe stenosis in the right superior division of the middle cerebral artery and moderate stenosis in the distal aspect of bilateral anterior, middle, and posterior cerebral arteries (Figure 2). His transesophageal echocardiogram was normal, and transcranial Doppler (TCD) showed no evidence of vasospasm or elevated velocities. Figure 1. Axial diffusion-weighted imaging showing multiple areas of restricted diffusion consistent with multifocal acute ischemia. Figure 2. Computed tomographic angiogram showing multifocal stenosis in different vascular territories most pronounced in the left internal carotid artery terminus. He appeared stable with no obvious changes on clinical examination. The hematology team was consulted, but they did not think he was a candidate for exchange transfusion given his normal HgB, normal MCV, few peripheral sickle cells, and most importantly, because of compound heterozygosity with HbC. Given the uncertainty of stroke pathogenesis and lack of treatment consensus, repeat brain imaging was performed demonstrating new punctate areas of restricted diffusion (Figure 3). Updated TCDs …

Reduced Cardiovascular Functions inPatients with Alzheimer's Disease.

Previous studies have suggested that cardiovascular functions might play a critical role in Alzheimer's disease (AD) pathogenesis. However, the relationship among heart function, blood flow of cerebral vessels, and AD remains unclear. In the present study, AD patients (n = 34) and age- and gender-matched cognitively normal controls (n = 34) were recruited. Demographic and comorbidity information was collected. The ejection fraction was measured using echocardiography, and the mean velocity, pulsatility index (PI), and resistance index (RI) of the basilar artery (BA), left terminal internal carotid artery (LTICA), and right terminal internal carotid artery (RTICA) were measured using transcranial Doppler. The data of lacunae, white matter changes, and plaques in the aortic arch and carotid arteries were collected from brain magnetic resonance imaging and computed tomography angiography images. Compared with normal controls, AD patients had lower ejection fractions and cerebral blood flow velocities and higher RI and PI in the BA, LTICA, and RTICA, as well as more plaques in the aortic and carotid arteries. In the multivariate logistic regression analysis, the ejection fraction and the mean velocity of the BA and LTICA were independently associated with AD after adjusting for age, gender, education, vascular risk factors, arterial plaques, and brain ischemic lesions detected in the brain images. These findings suggest that heart function and vascular condition may play important roles in AD pathogenesis. Improving cardiovascular functions could be a promising approach for the prevention and treatment of AD.

A Young Woman with Sudden Hemiparesis

Abstract: Stroke related to cerebral vasospasm may have the same appearance that ischemic stroke of other causes. The correct diagnosis is critical to avoid inappropriate treatments as thombolysis and anticoaglant therapy. In this case, a previous young healthy woman presented with acute onset of right-sided hemiplegia and expressive aphasia. Interpretation of Magnetic Resonance Images was challenging: acute ischemia, severe vasospasm, no signs of subarachnoid hemorrhage or intra-arterial thrombi, no evidence of cervical artery dissection. Cerebral angiography allowed to conclude that a ruptured small aneurysm was responsible for stroke, related to a spasm at the 7th day of aneurysm rupture concomitant of neck pain. The predictive MRI signs and the factors that contributed for the good outcome of a symptomatic vasospasm are discussed Case Presentation; A 30-year-old woman, without risk factors, presented with acute onset of right-sided deficit and expressive aphasia for potential thrombolysis.The interpretation of MRI was challenging. Various MRI findings help determine the etiology of stroke. A previously healthy 30-year-old woman presented to the stroke center for potential thrombolysis. She had presented sharp neck pain one week ago and neurological examination was unremarkable. She awoke at 8 am with right motor deficit. On arrival, 4 hours later, she was mutic with a Glasgow Coma Scale score of 15. She was normotensive (110/75 mmHg) with right-sided hemiplegia. Electrocardiogram did not demonstrate any arrthymia or other abnormality Emergent magnetic resonance imaging (MRI) of the brain displayed on diffusion-weighted imaging MRI (DWI) (Figure 1) and apparent coefficient diffusion map, (within 4 hours from onset), an acute ischemic stroke in the superficial territory of left middle cerebral artery (MCA), with normal fluid attenuated inversion recovery (FLAIR) except vessel hyperintensities (FVHs) proximal and distal to the sylvian fissure (Figures 2 and 3). T2* did not reveal any thrombus or hemorrhage. The presence of hyperintensity on DWI without corresponding hyperintensity on FLAIR, called “DWI-FLAIR mismatch indicate that the patient is likely within the time window for thrombolysis, Magnetic resonance angiography (MRA) visualized a severe vasospasm of the left terminal internal carotid artery and left MCA (M1 segment) (Figure 4). Intracranial and extracranial MRA was otherwise unremarkable, especially no dissection of the left carotid artery was identified, as also demonstrated by three-dimensional black blood (3D CUBE) T1 sequence. Diagnosis: Aneurysm rupture presenting as delayed ischemic stroke related to severe vasospasm Discussion: The interpretation of this imaging is challenging. Various MRI findings help determine the etiology of stroke and patient selection for acute ischemic stroke treatment (thrombolysis) [1]. The most common mechanisms of stroke in young population are cardioembolism and patent foramen ovale, and dissection of the cervical arteries. The first cause can be suspected when patients present acute multiple territorial lesions or a single large cortical and subcortical lesion on DWI and patent foramen ovale, another source of cardioembolism, usually causes small cortical lesions in vertebro-basilar territory. The presence of hypointense signals with blooming artifacts in the arterial system on T2* sequence (susceptible vessel sign) assess the presence of intra-arterial thrombi, usually associated with cardioembolic stroke. In this unusual presentation of stroke in a young patient without any risk factor, the absence of visualization of intra-arterial thrombus on T2* sequence and of carotid artery dissection (mural hematoma) on dedicated 3D CUBE sequence and the presence of a long spasm allow to conclude that a ruptured aneurysm was responsible for stroke, related to the spasm that occurred at the 7th day of rupture contemporary of neck pain. Seven days after the aneurysm rupture, a subarachnoid hemorrhage could not be identified on CT, nor on FLAIR and T2* MRI sequences : even if FLAIR sequence is more sensitive than CT and over a longer time period, the patient underwent MRI to late for examination at the 7th day [2]. Cerebral angiography identified a small aneurysm of the left anterior choroidal artery (Figure 5). Patients with DWI-FLAIR mismatch are likely to be within the time of adequate treatment. Endovascular treatment was performed using mechanical angioplasty and coiling. At 3-month follow-up, the patient was asymptomatic and MRA was normal (Figure 6). FHVs are imaging markers of both occlusion or narrowing when proximal to the ischemic core and of collateral system when distal. When present outside the ischemic core, they are associated with good outcome [3]. In the present case, the presence of collateral flow objective by FHV, an early treatment and the absence of risk factors contributed for the good outcome of a symptomatic vasospasm [4,5].

Reversible Changes of Posterior Cerebral Artery after Angioplasty for Moyamoya Disease: Report of a Case

Background: The changes of posterior cerebral arteries (PCAs) in Moyamoya disease (MMD) are often involved in the clinical setting. However, the changes of PCAs after recovering the hemodynamics of anterior circulation in MMD are not reported. Case Description: A 14-year-old patient was diagnosed as MMD with symptomatic stenosis in the right middle cerebral artery (MCA), asymptomatic stenosis in the left terminal internal carotid artery, and moyamoya-like vessels, stenotic lesion and an aneurysm were found in the right PCA, who was treated with balloon angioplasty in the right MCA. One month later, the patient suffered from transient ischemic attack in the right. DSA showed deteriorated severe stenosis in the left terminal portion of ICA and the proximal segment of MCA. The patient was performed angioplasty in the left ICA and MCA again. The follow-up angiography did not show any evidence of restenosis at the previous sites of stenosis after 18 months. Interestingly, the aneurysm and collateral vessels were disappeared as well as the stenotic vessel in the right PCA was recovered completely. Conclusion: Our findings indicated that the pathologic changes of PCA are reversible after recovering the hemodynamic of the anterior circulation in MMD. It is important to understand the pathophysiological changes of posterior circulation in MMD.

Successful endovascular stroke therapy in a 103-year-old woman

People older than 80 years of age constitute the most rapidly growing age group in the world. Several trials confirming superior efficacy of endovascular therapy did not have an upper...

Abstract T P13: Reversed Ischemic Attack (Ria): Proposal for a New Terminology in the Era of Thrombolytic Therapy

Background and Purpose: Cerebral ischemic attacks are classically known to cause either permanent injury in the case of ‘stroke’ or transient dysfunction without permanent injury in the case of ‘TIA’. The latter occurs due to timely restoration of cerebral blood flow and implies a spontaneous process. With thrombolytic therapy (intravenous or intra-arterial) complete reperfusion is possible and can lead in some patients to complete reversal of the ischemic insult both clinically and radiographically. This entity is inadequately characterized by the current stroke terminology. Methods: A retrospective review of a prospectively maintained database identified 800 patients who underwent acute endovascular reperfusion therapy. Inclusion criteria were: complete clinical recovery without evidence of infarction on follow up MRI (DWI sequence). Results: We identified 8 patients. Intravenous alteplase followed by intra-arterial therapy was administered in 37.5% of cases. Admission NIHSS ranged from 8-21 and recanalization occurred between 45-490 minutes of symptom onset. The site of occlusion was as follows: left internal carotid artery terminus (2, 25%), middle cerebral artery M1 segment (5, 62.5%) and middle cerebral artery M2 segment (1, 12.5%). Conclusions: A hitherto unreported condition of complete clinical and radiographic recovery after reperfusion therapy for large vessel intracranial occlusion is being described. Review of an endovascular database comprising 800 consecutive cases, revealed that the incidence of this entity is 1%. We postulate that in parallel to an increase in efficacy and utilization of revascularization modalities along with an increase in assessment of vessel patency prior to intravenous thrombolysis, recognition of this phenomenon will increase and propose the term ‘Reversed’ Ischemic Attack (RIA) to address a deficiency in terminology currently associated with this condition.

Last resort: case of clot translocation in intra-arterial stroke therapy

A patient was taken for emergent intra-arterial stroke therapy for an acute left middle cerebral artery stroke syndrome, with CT angiography showing a left internal carotid artery (ICA) occlusion. Through...

Successful Recanalization of a Septic Embolus with a Balloon Mounted Stent after Failed Mechanical Thrombectomy

Cardiac emboli are a feared complication for patients with left ventricular assist devices (LVAD). Septic emboli are rare but carry a poor prognosis in the setting of large artery occlusion. We report the case of a 24-year-old woman who presents with a left internal carotid artery terminus occlusion secondary to a septic emboli from a LVAD. The patient was not a candidate for intravenous thrombolytics due to an elevated international normalized ratio, and thus was taken for intra-arterial treatment. Initial treatment with mechanical thrombectomy and balloon angioplasty was not successful; thus, a balloon-mounted coronary stent was placed to achieve successful recanalization. Fragments of thrombus on the mechanical thrombectomy device revealed gram-positive bacilli on gram stain. Patients with large artery occlusion due to a septic embolus can be successfully treated with endovascular therapies in select patients.

Post eclamptic aneurysmal rupture subarachnoid haemorrhage diagnosed in the puerperium

AbstractThe incidence of subarachnoid and / or intracerebral haemorrhage in women during pregnancy is rare. The risk depends on the stage of pregnancy, but seems to be highest during the late third trimester, during delivery and in the puerperium. Headache can be a symptom of both preeclampsia, subarachnoid haemorrhage and other pathologies or conditions. It is essential for pregnant women with a suspected ruptured aneurysm to be investigated and treated without delay, irrespective of fear of harm to the foetus, to avoid complications from aneurysm rupture.This case study presents a 39‐year‐old woman who was 35 weeks and 3 days pregnant with known preeclampsia. She endured a headache for the three days leading up to the delivery with associated diplopia on the third day, but these symptoms were thought to be related to her preeclampsia. Over the three hours following childbirth, her headache became more severe and she suffered from vomiting, loss of vision, torticollis and seizures. Computed tomography (CT) of her head revealed a subarachnoid haemorrhage while CT angiography of the Circle of Willis failed to reveal an aneurysm and 4‐vessel angiography only demonstrated an area slightly suspicious for the presence of an aneurysm. 3D rotational angiography clearly demonstrated a 1–2 mm aneurysm superior to the left terminal internal carotid artery. In this case, 3D rotational angiography proved to be a valuable additional technique. This patient underwent surgery for her ruptured aneurysm and has made an excellent recovery.

Expanding the treatment window with mechanical thrombectomy in acute ischemic stroke

Acute ischemic stroke is a common disease associated with high mortality and significant long-term disability. Treatment options for acute ischemic stroke continue to evolve and include pharmaceutical and mechanical therapies. With the recent US Food and Drug Administration approval of a new device for mechanical thrombectomy, the options available for treatment of acute ischemic stroke have been expanded. Thrombolytic therapy is generally given intravenously in the first 3 h and up to 6 h via the intraarterial route for pharmacological clot disruption. The maximum time-frame for mechanical thrombectomy devices has yet to be determined. A 78-year-old female presented to the emergency room with a dense right hemiparesis, leftward gaze preference and dense global aphasia. Eight hours after symptom onset, left carotid angiography confirmed a left internal carotid artery terminus occlusion. A single pass was made through the clot with an X6 Merci Retriever device. After a single pass, the vessel was reopened and normal flow in the left internal carotid artery was demonstrated. At the time of discharge, her neurological deficits had improved significantly. Furthermore, the final infarct area, as demonstrated on magnetic resonance imaging, was probably much smaller than it would have been if the vessel had not been recanalized. We report the use of a new mechanical thrombectomy device 8 h after onset of ischemic symptoms, with substantial subsequent improvement in neurological outcome. In selected cases, use of the Merci Retriever can result in improved outcomes beyond the traditional 6-h window used for intraarterial pharmacological thrombolysis.

Intra-arterial papaverine-induced seizures: case report and review of the literature

BACKGROUND Microcatheter-guided intra-arterial (IA) papaverine infusion in conjunction with balloon angioplasty is an available therapy for patients with symptomatic vasospasm after subarachnoid hemorrhage (SAH) that is refractory to hypertensive, hypervolemic therapy. However, side effects and complications have been reported in association with its use. CASE DESCRIPTION We report on a patient who developed symptomatic vasospasm after subarachnoid hemorrhage due to rupture of a left terminal internal carotid artery (ICA) saccular aneurysm. Seven days after the hemorrhage and 4 days after surgical clipping, the patient developed aphasia and right hemiparesis due to vasospasm, which was refractory to maximal medical treatment with volume and blood pressure elevation. Cerebral angiography identified severe narrowing of distal ICA and proximal middle cerebral artery segments bilaterally. These findings partially resolved after balloon angioplasty. However, after 300 mg of IA papaverine, the patient developed generalized convulsions. This occurred despite therapeutic serum levels of phenytoin. Twenty-four hours later, after brief neurologic improvement, recurrent neurologic deficits prompted repeat papaverine administration. Seizures again occurred after the administration of 240 mg of IA papaverine and prevented administration of the full dose. The patient did not develop further seizures and her neurologic deficits continue to resolve. CONCLUSIONS IA papaverine-induced seizures are infrequently reported. This potential complication should be considered when papaverine administration is entertained in the treatment of anterior circulation refractory symptomatic vasospasm after SAH.